PRESENTING
FELLOW

THE
CASE

a twelve
year old boy presented to a regional hospital with acute pneumonia and
a twelve month history of progressive dyspnea.

HISTORY

Initial Presentation
A
12 year old boy presented to a regional hospital with a 3 week history
of productive cough and night sweats. On examination he was hypoxic
with crackles in both bases. A chest radiograph showed bibasalar increased
markings. A diagnosis of acute bacterial pneumonia was appropriately
made and he was treated with intravenous Cefuroxime as well as oxygen
via nasal prongs with no improvement after 3 days.

Further
history revealed 12 months of progressive dyspnea, initially with exercise
and recently with climbing stairs. He had no history of wheeze or cough.
He had not traveled outside Canada and was a non smoker.

Past
medical historyHe
was born at term with no complications. He was not taking any regular
medications apart from Chinese herbs. He had not had any surgery. He
had not been immunized. There was a family history of Von Willebrands
disease but no other medical conditions.

His
medical history was essentially unremarkable, with no previous hospital
admissions. He had been seen in the emergency department twice, once
with abdominal pain and once with acute dyspnea. No diagnosis was reached
at either visit and symptoms settled with minimal treatment.

Further
questioning revealed a 2 month history of occasional cramping abdominal
pain in the upper abdomen, on average 3 times a day, usually after meals
and particularly those containing wheat. He described some constipation,
but there was no diarrhea, no vomiting and no blood loss. There had
been no contact with other people with illness. Over the past 3 months
he had lost approximately 10 lb in weight.